Complaint Form

Complaint

VI Procedures and Compliance
Section I:
Accessible Format Requirements :
Section II:
Are You Filing This Complaint On Your Own Behalf? :
If you answered “yes” to this question, go to Section III.
If not, please supply the name and relationship of the person for whom you are complaining:
Please Confirm You Have Obtained The Permission Of The Aggrieved Party If You Are Filing On Behalf Of A Third Party.
Section III:
I Believe The Discrimination I Experienced Was Based On.
Section IV:
Have You Previously Filed A Title VI Complaint With This Agency?
Section V:
Have You Previously Filed A Title VI Complaint With Any Other Federal, State, Or Local Agency, Or With Any Federal Or State Court?
Please provide information about a contact person at the agency/court where the complaint was filed.:
You may attach any written materials or other information that you think is relevant to your complaint. Signature and date required below.
Section VI:
14 + 7 =
CHEROKEE COUNTY DISABILITIES AND
SPECIAL NEEDS BOARD